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Show facilities and with hospital systems. This knowledge gathering identified the use of standardized procedures as a central element in hospitals' strategies to ensure the reliable delivery of recommended health care services across a wide range of clinical topics. Optimally, svich procedures can aid performance through improved information access and communication. A brief review of hospital practices related to 6th SOW indicators suggested variability in the effectiveness of the procedures in use. It also introduced important instances wherein no procedures had been implemented. In response, the Healthlnsight inpatient team developed a multifaceted intervention strategy informed by principles drawn from the fields of human factors psychology, organizational risk management, and commercial aviation safety. Intervention activities focused on a structured review of the design, implementation, and maintenance of standardized procedures related to 6th SOW clinical indicators. This review was intended to guide hospital teams to process or task design characteristics likely to interfere with (or fail to support) reliable performance. The review relied on direct evaluation of procedures, using hospital teams' existing knowledge, rather than additional data collection. It also promoted the adoption of standardized procedures where none existed. Complementary intervention activities emphasized the potential role of pharmacists and patient care nurses in ensuring the reliable delivery of care. One-page "clmical care alerts" that provided background and indications for the use of recommended therapies and pre-printed post-it reminders were used to prepare these non-physician members of the clinical care team to recognize potential omissions and effectively prompt corrective action. Additional intervention activities included the promotion of collaborative sharing of practices within the local health care community, performance data feedback, and dissemination of treatment guideline recommendations to physicians. Outpatient Quality Improvement Activities At the outset of the 6th SOW, outpatient quality improvement activities faced the challenge of forging productive working relationships with groups of providers with whom we had not worked before. Early in the 6th SOW, review of scientific literature related to the quality indicators and customer knowledge gathering lead to the development of a multifaceted intervention model. This model focused on facilitating changes for improving preventive care in addition to working with topic-specific community groups. Clinics were prioritized for recruitment by their location and number of Medicare patients. Healthlnsight worked closely with primary care physicians and their staffs to develop processes for systematically providing preventive care services and referrals. We presented examples of effective interventions such as flow sheets, patient registries, chart stickers, routine patient assessments, and pre-printed referral forms. Each participating office practice was assigned a liaison to assist hi implementing these changes. Potential benefits of participation for physicians and their staff included reduced time to assess and deliver preventive care, improved health status for patients, prevention of complications and reduction of hospi-talizations, and increased convenience and satisfaction with preventive care. RESULTS The Medicare clinical performance monitoring system supports statewide analysis within the major areas of focus for the contract (inpatient and outpatient) and by clinical topic area. Sample sizes limit meaningful analysis of provider-specific performance. Performance-based contracting decisions for Medi- care QIOs are based on state-to-state comparisons using quality indicator averages weighted according to their clinical importance and program priorities; except as noted, all results reported are weighted according to this scheme. Quality indicator improvement is reported in terms of relative improvement (RI - the percentage reduction in the baseline failure rate) in baseline (1998) to re-measurement (2000) performance. Inpatient Clinical Topic Areas Comparison of baseline and re-measurement inpatient results showed a 27.3% relative improvement (RI) statewide. Improvement was observed in 15 of the 16 indicators and in all four inpatient clinical topic areas (See Table 1). • The single heart failure indicator had an RI of 24.3%. • The weighted average RI for the three stroke indicators was 18.7%. • The six quality indicators for which RI is computed for acute myocardial infarction is measured averaged 32.2%. The time to initial reperfusion indicator was decreased by 13 minutes. • The five inpatient pneumonia quality indicators averaged 33.9% RI. driven largely by substantial improvement in the immunization indicators. The RI for 17 targeted hospitals (with all indicator results weighted equally) was 31.9%; five (29%) had greater than 45% RI, six (35%) had RI between 25% and 39%, and six (35%) had RI less than 10%, including four with negative relative improvement. All other facilities combined had a 22.2% RI. Nationally, Utah's 27.3% RI on inpatient clinical topic areas ranked #1 hi a comparison of 52 states and territories, Puerto Rico, and the District of Columbia (see Figure 1). This level of improvement is more than double the 9.9% median improvement observed and is 29% greater than the improvement observed in the second ranked state. By clinical topic area, Utah's national RI rankings were: • Heart failure - 5th • Stroke - 9th Acute myocardial infarction - 1st Pneumonia - 1st Utah's ranking on the combined inpatient clmical topic areas improved by 15 positions, from #16 at baseline to #1 at re-measurement. Outpatient Clinical Topic Areas Comparison of baseline and remeasurement outpatient results showed a 16.3% RI statewide (See Table 1). Improvement was observed in five of the six indicators and in all three outpatient clinical topic areas. • The three diabetes indicators had a weighted average RI of 31.8%. • Biannual mammography had a 12.3% RI. • The weighted average RI for the two immunization indicators was 4.7%. Nationally, Utah's 16.3% RI on outpatient clinical topic areas ranked #39 in a comparison of 52 states and territories, Puerto Rico, and the District of Columbia (see Figure 2). This level of improvement is somewhat less than 19.6% median improvement observed. By clinical topic area, Utah's national improvement rankings were: Utah's Health: An Annual Review Volume IX 134 |